Course 8 Medical Tests Used to Diagnose Painful Conditions

Nelson Hendler MD MSFormer Assistant Professor of NeurosurgeryFormer Clinical Director of Mensana ClinicFormer Associate Professor of Physiology

University of Maryland School of Dental SurgeryPast president-American Academy of Pain Management

bull Business Week listed the 8 best pain clinics in the

United States including Mayo Clinic Mensana Clinic Johns Hopkins Hospital and Cleveland Clinic (1)

bull The medical team from two of these clinics used 55 medical tests to help clarify the origin of pain

bull Most of these were physiological testsbull What follows is a list of the tests and what they

actually tell a physician about the cause of the pain based on outcome studies

bull These tests are part of the Treatment Algorithm of the Diagnostic Paradigm found at wwwMarylandClinicalDiagnosticscom

(1) Business Week pages 104-105 Jan 27 1992

Selecting the Correct Testbull While this sounds self-evident very often

physicians donrsquot apply logic when selecting testsbull If a patient tells a doctor that his neck pain is

worse when bending his head forward or backwards but feels fine when upright it would be logical to order X-rays when the patient is leaning forward or backward This is not often done

bull Infection is a metabolic process creating cellular activity at a microscopic level So a physiological test such as a bone scan would reveal more about the process than an anatomical test such as an X-ray or MRI

X-rays versus Flexion Extension X-rays

bull Most patients complain of worse pain when they lean forward or backwards

bull Static (upright) X-rays do not demonstrate movement between the vertebral bodies

bull Flexion-Extension X-rays show what happens to the vertebral bodies when there is motion forward and backwards

bull Like a partially broken twig- the defect is not evident until the twig is put under tension

The BONE SCAN consists of injecting a radioactive tracer such as technetium-99m-MDP into the vein and then scanned with a gamma camera a device sensitive to the radiation emitted by the injected material The tracer accumulates at areas of inflammation bone growth cancer and infection The test is sensitive but not specific

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

bull Business Week listed the 8 best pain clinics in the

United States including Mayo Clinic Mensana Clinic Johns Hopkins Hospital and Cleveland Clinic (1)

bull The medical team from two of these clinics used 55 medical tests to help clarify the origin of pain

bull Most of these were physiological testsbull What follows is a list of the tests and what they

actually tell a physician about the cause of the pain based on outcome studies

bull These tests are part of the Treatment Algorithm of the Diagnostic Paradigm found at wwwMarylandClinicalDiagnosticscom

(1) Business Week pages 104-105 Jan 27 1992

Selecting the Correct Testbull While this sounds self-evident very often

physicians donrsquot apply logic when selecting testsbull If a patient tells a doctor that his neck pain is

worse when bending his head forward or backwards but feels fine when upright it would be logical to order X-rays when the patient is leaning forward or backward This is not often done

bull Infection is a metabolic process creating cellular activity at a microscopic level So a physiological test such as a bone scan would reveal more about the process than an anatomical test such as an X-ray or MRI

X-rays versus Flexion Extension X-rays

bull Most patients complain of worse pain when they lean forward or backwards

bull Static (upright) X-rays do not demonstrate movement between the vertebral bodies

bull Flexion-Extension X-rays show what happens to the vertebral bodies when there is motion forward and backwards

bull Like a partially broken twig- the defect is not evident until the twig is put under tension

The BONE SCAN consists of injecting a radioactive tracer such as technetium-99m-MDP into the vein and then scanned with a gamma camera a device sensitive to the radiation emitted by the injected material The tracer accumulates at areas of inflammation bone growth cancer and infection The test is sensitive but not specific

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

Selecting the Correct Testbull While this sounds self-evident very often

physicians donrsquot apply logic when selecting testsbull If a patient tells a doctor that his neck pain is

worse when bending his head forward or backwards but feels fine when upright it would be logical to order X-rays when the patient is leaning forward or backward This is not often done

bull Infection is a metabolic process creating cellular activity at a microscopic level So a physiological test such as a bone scan would reveal more about the process than an anatomical test such as an X-ray or MRI

X-rays versus Flexion Extension X-rays

bull Most patients complain of worse pain when they lean forward or backwards

bull Static (upright) X-rays do not demonstrate movement between the vertebral bodies

bull Flexion-Extension X-rays show what happens to the vertebral bodies when there is motion forward and backwards

bull Like a partially broken twig- the defect is not evident until the twig is put under tension

The BONE SCAN consists of injecting a radioactive tracer such as technetium-99m-MDP into the vein and then scanned with a gamma camera a device sensitive to the radiation emitted by the injected material The tracer accumulates at areas of inflammation bone growth cancer and infection The test is sensitive but not specific

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

X-rays versus Flexion Extension X-rays

bull Most patients complain of worse pain when they lean forward or backwards

bull Static (upright) X-rays do not demonstrate movement between the vertebral bodies

bull Flexion-Extension X-rays show what happens to the vertebral bodies when there is motion forward and backwards

bull Like a partially broken twig- the defect is not evident until the twig is put under tension

The BONE SCAN consists of injecting a radioactive tracer such as technetium-99m-MDP into the vein and then scanned with a gamma camera a device sensitive to the radiation emitted by the injected material The tracer accumulates at areas of inflammation bone growth cancer and infection The test is sensitive but not specific

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

The BONE SCAN consists of injecting a radioactive tracer such as technetium-99m-MDP into the vein and then scanned with a gamma camera a device sensitive to the radiation emitted by the injected material The tracer accumulates at areas of inflammation bone growth cancer and infection The test is sensitive but not specific

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

When to use an MRIbull MRIs can be used to detect space occupying lesions

where a tumor or bone is compressing a soft tissue such as a blood vessel or muscle

bull MRIs are not good for detecting damaged discs bull Jensen et al N Eng J Med rsquo94 reported 98

patients with no back pain but 27 had protruding disc The MRI had a 28 false positive rate

bull In 90 patients all of whom has a positve provocative discogram (a physiological test) 77 of them had no MRI findings (an anatomical test) such as Modic signs (vertebral end plate changes)

bull Therefore there is a 77 false negative rate for MRI

Braithwaite et al Eur Spine J rsquo98

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

Thermographybull This technique measures temperature differences

in the bodybull The technique can detect temperature changes

only to a depth of 5 centimeters or about 2 inches bull It cannot be used as a substitute for

mammography or for detecting disc disease(1)bull It can be used for detecting gross temperature

differences in a limb such as Complex Regional Pain Syndrome (type I) ndashsee next slide (2)

Uematsu S Hendler N Hungerford D Long D Ono N Thermography and Electromyography in the Differential Diagnosis

of Chronic Pain Syndromes and Reflex Sympathetic Dystrophy Electromyography and Clinical Neurophysiology Vol 21 pp165-182 1981

Hendler N Uematsu S Long D Thermographic Validation of Physical Complaints in Psychogenic Pain Patients Psychosomatics Vol 23 No 3 March 1982

bull

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

3D-CTbull This is a computer manipulation of a CT scan

which can detect bony lesions which may be missed by a regular CT (1)

bull In one article from Johns Hopkins 100 patients with no prior surgery had bony lesions on 3D-CT which were missed by a regular CT 56 of the time

bull 100 patients with prior lumbar surgery had bony lesions on 3D-CT which were missed by a regular CT 76 of the time (2)

bull (1)Hendler N Zinreich J Kozikowski J Three-Dimensional CT Validation of Physical Complaints in `Psychogenic Pain Patients Psychosomatics Vol 34 No 190-96 JanuaryFebruary 1993

bull (2) Zinreich SJ Long DM Davis R Quinn CB McAfee PC Wang Hbull Three-dimensional CT imaging in postsurgical failed back syndrome

J Comput Assist Tomogr 1990 Jul-Aug14(4)574-80

3D-CT of the Wrist with black arrow showing the linear fracture which had been missed by regular X-ray and plain CT scan 3D-CT is essentially a computer program which subtracts soft tissue from a CT

EMG-Nerve conduction studies

Neurometersbull Neurometers measure the three types of sensory nerves at the

frequencies specific for each nerve A beta A delta and C fibers

bull Electrical current is applied at one of three frequencies and the patients reports when he just begins to felt the electrical current

bull This current perception threshold determine if the nerve response is in the normal range or damaged

bull This test is specific for sensory nerves bull Raj P Chado H Angst M Heavner J Dotson RBrandstater M Johnson B Parris W Finch

PShahani BDhand U Mekhail N Daoud E HendlerN Somerville J Wallace M Panchal S Glusman S Jay G Palliyath S Longton W IrvingGldquoPainless Electrodiagnostic Current Perception Threshold and Pain Tolerance Threshold Values in CRPS Subjects and Healthy Controls A Multicenter Studyrdquo Pain Practice Vol 1 No 1 53 60 March 2001

bull Masson EA Boulton AJ The Neurometer validation and comparison with conventional tests for diabetic neuropathy Diabet Med 19918 Spec NoS63-6

bull

Vascular flow studies (Doppler)This test will determine if there is a blockage or compression of a blood vessel Print outs of actual studies are shown below The results of the tests are visually obvious If the vessel is unobstructed or not compressed then the pulse is clearly seen on the recording device Blockage produces the flat line

SPECT Scanbull A single-photon emission computerized tomography (SPECT)

scan helps analyze the function of internal organs bull A SPECT scan is a type of nuclear imaging test which means it

uses a radioactive substance and a special camera to create 3-D pictures

bull A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active

bull SPECT can be helpful in determining which parts of the brain are being affected by dementia clogged blood vessels seizures encephalitis and head injuries

bull Areas of bone healing or cancer progression usually light up on SPECT scans to help diagnose hidden bone fractures and the progression of cancer that has spread to the bones

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

EMG-Nerve conduction studies

Neurometersbull Neurometers measure the three types of sensory nerves at the

frequencies specific for each nerve A beta A delta and C fibers

bull Electrical current is applied at one of three frequencies and the patients reports when he just begins to felt the electrical current

bull This current perception threshold determine if the nerve response is in the normal range or damaged

bull This test is specific for sensory nerves bull Raj P Chado H Angst M Heavner J Dotson RBrandstater M Johnson B Parris W Finch

PShahani BDhand U Mekhail N Daoud E HendlerN Somerville J Wallace M Panchal S Glusman S Jay G Palliyath S Longton W IrvingGldquoPainless Electrodiagnostic Current Perception Threshold and Pain Tolerance Threshold Values in CRPS Subjects and Healthy Controls A Multicenter Studyrdquo Pain Practice Vol 1 No 1 53 60 March 2001

bull Masson EA Boulton AJ The Neurometer validation and comparison with conventional tests for diabetic neuropathy Diabet Med 19918 Spec NoS63-6

bull

Vascular flow studies (Doppler)This test will determine if there is a blockage or compression of a blood vessel Print outs of actual studies are shown below The results of the tests are visually obvious If the vessel is unobstructed or not compressed then the pulse is clearly seen on the recording device Blockage produces the flat line

SPECT Scanbull A single-photon emission computerized tomography (SPECT)

scan helps analyze the function of internal organs bull A SPECT scan is a type of nuclear imaging test which means it

uses a radioactive substance and a special camera to create 3-D pictures

bull A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active

bull SPECT can be helpful in determining which parts of the brain are being affected by dementia clogged blood vessels seizures encephalitis and head injuries

bull Areas of bone healing or cancer progression usually light up on SPECT scans to help diagnose hidden bone fractures and the progression of cancer that has spread to the bones

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

Neurometersbull Neurometers measure the three types of sensory nerves at the

frequencies specific for each nerve A beta A delta and C fibers

bull Electrical current is applied at one of three frequencies and the patients reports when he just begins to felt the electrical current

bull This current perception threshold determine if the nerve response is in the normal range or damaged

bull This test is specific for sensory nerves bull Raj P Chado H Angst M Heavner J Dotson RBrandstater M Johnson B Parris W Finch

PShahani BDhand U Mekhail N Daoud E HendlerN Somerville J Wallace M Panchal S Glusman S Jay G Palliyath S Longton W IrvingGldquoPainless Electrodiagnostic Current Perception Threshold and Pain Tolerance Threshold Values in CRPS Subjects and Healthy Controls A Multicenter Studyrdquo Pain Practice Vol 1 No 1 53 60 March 2001

bull Masson EA Boulton AJ The Neurometer validation and comparison with conventional tests for diabetic neuropathy Diabet Med 19918 Spec NoS63-6

bull

Vascular flow studies (Doppler)This test will determine if there is a blockage or compression of a blood vessel Print outs of actual studies are shown below The results of the tests are visually obvious If the vessel is unobstructed or not compressed then the pulse is clearly seen on the recording device Blockage produces the flat line

SPECT Scanbull A single-photon emission computerized tomography (SPECT)

scan helps analyze the function of internal organs bull A SPECT scan is a type of nuclear imaging test which means it

uses a radioactive substance and a special camera to create 3-D pictures

bull A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active

bull SPECT can be helpful in determining which parts of the brain are being affected by dementia clogged blood vessels seizures encephalitis and head injuries

bull Areas of bone healing or cancer progression usually light up on SPECT scans to help diagnose hidden bone fractures and the progression of cancer that has spread to the bones

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

Vascular flow studies (Doppler)This test will determine if there is a blockage or compression of a blood vessel Print outs of actual studies are shown below The results of the tests are visually obvious If the vessel is unobstructed or not compressed then the pulse is clearly seen on the recording device Blockage produces the flat line

SPECT Scanbull A single-photon emission computerized tomography (SPECT)

scan helps analyze the function of internal organs bull A SPECT scan is a type of nuclear imaging test which means it

uses a radioactive substance and a special camera to create 3-D pictures

bull A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active

bull SPECT can be helpful in determining which parts of the brain are being affected by dementia clogged blood vessels seizures encephalitis and head injuries

bull Areas of bone healing or cancer progression usually light up on SPECT scans to help diagnose hidden bone fractures and the progression of cancer that has spread to the bones

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

SPECT Scanbull A single-photon emission computerized tomography (SPECT)

scan helps analyze the function of internal organs bull A SPECT scan is a type of nuclear imaging test which means it

uses a radioactive substance and a special camera to create 3-D pictures

bull A SPECT scan can show how blood flows in the heart or what areas of the brain are more active or less active

bull SPECT can be helpful in determining which parts of the brain are being affected by dementia clogged blood vessels seizures encephalitis and head injuries

bull Areas of bone healing or cancer progression usually light up on SPECT scans to help diagnose hidden bone fractures and the progression of cancer that has spread to the bones

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

SPECT SCAN IMAGE

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

Indium 111 Scanbull The indium white blood cell scan also called

indium leukocyte imaging indium-111 scanrdquo is a nuclear medicine procedure in which white blood cells are removed from the patient tagged with the radioisotope Indium-111 and then injected intravenously into the patient The tagged white blood cells subsequently localize to areas of relatively new infection The study is particularly helpful in differentiating conditions such as osteomyelitis from decubitus ulcers for assessment of route and duration of antibiotic therapy

Indium 111 Scan Imagebull 56 year old female presents bull with nausea flushingbull and low back pain bull No history of hypertensionbull Blood work revealed elevatedbull levels of white blood cells bull and sed rate bull The right kidney showedbull markedly increased uptake bull Compatible with a severe bull acute kidney infection

Gallium Scanbull A gallium scan is a type of nuclear medicine study that uses a

radioactive tracer to obtain images of a specific type of tissue or disease state of tissue Gallium salts like gallium citrate and gallium nitrate are used The form of salt is not important since it is the freely dissolved gallium ion Ga+3 which is active For these applications the radioactive isotope gallium-67 (67Ga) which has a decay half-life of 326 days is used

bull Gallium-67 is immaged with a gamma camera with a SPECT camera or with SPECTCT hybrid machines

bull Gallium is taken up by tumors inflammation and both acute and chronic infection allowing these pathological processes to be imaged by nuclear scan techniques

bull Gallium is particularly useful in imaging osteomyelitis that does not involve the spine

Gallium Scan Images

Gallium scan of the feet showing gout in the big toe and old stress fractures in the metatarsals Gallium is better for older lesions than Indium but Indium is more specific for acute infection A bone scan is less specific and would have also identified these lesions but couldnrsquot differentiate between infection and inflamation

PET Scanbull PET stands for positron emission tomographybull Radioactive medicine is produced in a cyclotron bull The radioactive medicine is then tagged to a

natural chemical like glucose water or ammonia

bull The tagged chemical is a radiotracer bull The radiotracer is injected into the patientbull Tomography shows how the trace is taken up

by the bodybull This measures activity and function of an organ

PET Scan ImagesPET scan images can be used to determine the function of an organ such brain function or kidney function

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Gallium Scanbull A gallium scan is a type of nuclear medicine study that uses a

radioactive tracer to obtain images of a specific type of tissue or disease state of tissue Gallium salts like gallium citrate and gallium nitrate are used The form of salt is not important since it is the freely dissolved gallium ion Ga+3 which is active For these applications the radioactive isotope gallium-67 (67Ga) which has a decay half-life of 326 days is used

bull Gallium-67 is immaged with a gamma camera with a SPECT camera or with SPECTCT hybrid machines

bull Gallium is taken up by tumors inflammation and both acute and chronic infection allowing these pathological processes to be imaged by nuclear scan techniques

bull Gallium is particularly useful in imaging osteomyelitis that does not involve the spine

Gallium Scan Images

Gallium scan of the feet showing gout in the big toe and old stress fractures in the metatarsals Gallium is better for older lesions than Indium but Indium is more specific for acute infection A bone scan is less specific and would have also identified these lesions but couldnrsquot differentiate between infection and inflamation

PET Scanbull PET stands for positron emission tomographybull Radioactive medicine is produced in a cyclotron bull The radioactive medicine is then tagged to a

natural chemical like glucose water or ammonia

bull The tagged chemical is a radiotracer bull The radiotracer is injected into the patientbull Tomography shows how the trace is taken up

by the bodybull This measures activity and function of an organ

PET Scan ImagesPET scan images can be used to determine the function of an organ such brain function or kidney function

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Gallium Scan Images

Gallium scan of the feet showing gout in the big toe and old stress fractures in the metatarsals Gallium is better for older lesions than Indium but Indium is more specific for acute infection A bone scan is less specific and would have also identified these lesions but couldnrsquot differentiate between infection and inflamation

PET Scanbull PET stands for positron emission tomographybull Radioactive medicine is produced in a cyclotron bull The radioactive medicine is then tagged to a

natural chemical like glucose water or ammonia

bull The tagged chemical is a radiotracer bull The radiotracer is injected into the patientbull Tomography shows how the trace is taken up

by the bodybull This measures activity and function of an organ

PET Scan ImagesPET scan images can be used to determine the function of an organ such brain function or kidney function

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

PET Scanbull PET stands for positron emission tomographybull Radioactive medicine is produced in a cyclotron bull The radioactive medicine is then tagged to a

natural chemical like glucose water or ammonia

bull The tagged chemical is a radiotracer bull The radiotracer is injected into the patientbull Tomography shows how the trace is taken up

by the bodybull This measures activity and function of an organ

PET Scan ImagesPET scan images can be used to determine the function of an organ such brain function or kidney function

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

PET Scan ImagesPET scan images can be used to determine the function of an organ such brain function or kidney function

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Cine MRI for TMJbull Xavier Tomas MD Jaume Pomes MD Juan Berenguer MD Llorenccedil Quinto MD Carlos Nicolau MD Josep Maria Mercader MD and Vicente Castro MD MR Imaging of

Temporomandibular Joint Dysfunction A Pictorial ReviewDentomaxillofac Radiol July 1 2010 395 270-276

When the mandible is in the closed-mouth position the thick posterior band of the meniscus lies immediately above the condyle near the twelve orsquoclock position

Disk injuries are the most common cause of TMJ dysfunction MR imaging is currently the standard imaging technique for diagnosing disk injuries In the early stages of internal derangement the disk retains its normal shape Over time however the displaced disk is deformed by thickening of the posterior band and reduction in the mass of the anterior band and the central thin area leading to a biconvex or rounded disk (23) Irregular and rounded morphologic features are universally considered to indicate disease

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Cine MRI images

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Root blocks-Compare to facet blockbull L3-L4 root

Normal Size

Neural Foramin

Normal Disc Height

Normal Vertebral Body

Alignment

Ligament holding vertebral bodies together

Vertebral slippage due to reduced disc space height and lax ligament

Root Block

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Sympathetic block-Stellate Ganglion

This is used to determine if a patient has complex regional pain syndrome in the arm If effective the arm will get warm and the pain will disappear The block will last about an hour

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Lumbar sympathetic blockA block of the lumbar sympathetic ganglion which reside outside of the spinal canal Used for the diagnosis of complex regional pain syndrome

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Peripheral Nerve Blocks-a testA peripheral nerve block of a mixed motor sensory nerve clarifies the source of pain 05 Marcaine should be used to provide a sensory block without creating a motor block If the pain goes away the source of the pain has been diagnosed The effect will last about an hour

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Neuropsychological Testingbull This is the most reliable way to determine brain

damage after a head injury or severe whiplashbull There are a variety of questionnaires involved in

this testing which should take 6-8 hoursbull These tests will determine memory loss trouble

with executive function-decision making calculation capabilities logical thinking and other function

bull Preliminary research shows no consistent overlap of abnormalities with PET scans SPECT scans and EEG The tests measure different functions

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

SCL-90bull This test was developed by Len Derogatis PhD

at Johns Hopkins Hospitalbull The 90 questions measure the psychological

state of a patient which changes every 5 to 7 days

bull This test can be used to measure improvement in depression anxiety and other conditions in response to treatment

bull The test is self administered

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Pain Validity Testbull Developed by a team of physicians from Johns

Hopkins Hospital with 7 publications about itbull The test can predict which patient will have a

moderate or severe abnormality on objective medical tests with 95 accuracy

bull The test can predict who will not have any abnormalities with 85 accuracy

bull The test is self administered over the Internet in English or Spanish and results returned within 5 minutes after completion

bull See wwwMarylandClinicalDiagnosticscom

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Body Jacket with Thigh Spika-a test This back brace is the only back brace which stabilizes the L5-S1 spinal segment as well as the rest of the lumbar segments This body jacket is a test If the patient gets relief with this jacket then this is indicative of an unstable lumbar segment and the patient should have facet blocks root blocks and provocative discograms

If the patient has a fusion the brace can be used post-operatively

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

2 poster brace-a test

This brace stabilizes the cervical spine The patient wears it for at least a week If it takes away the pain then the patient should have cerivical facet blocks cervical root blocks and provocative discograms If the patient has an fusion the brace can be used post-operatively

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Blood Studiesbull Routinely a patient with muscle and joint

disease should have a Lyme titer sed rate C3 C4 rheumatoid factor uric acid levels ANA SSA and SSB

bull Patients with nerve entrapments should have TSH T4 and thyroid antibody testing

bull Patients with peripheral neuropathy should have studies for blood sugar A1C glycohemoglobin RPR STS Lyme titer B12

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value

Epidurals of no diagnostic value The available literature included only blind epidural

injections without fluoroscopy The indicated evidence is positive (Level II-2) for short-

term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis

The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections

Parr AT Diwan S Abdi SLumbar interlaminar epidural injections in managing chronic low back and lower extremity pain a systematic review Pain Physician 2009 Jan-Feb12(1)163-88

• Course 8 Medical Tests Used to Diagnose Painful Conditions
• Selecting the Correct Test
• Slide 4
• Slide 5
• X-rays versus Flexion Extension X-rays
• Slide 7
• When to use an MRI
• Thermography
• Slide 10
• 3D-CT
• Slide 12
• Slide 13
• EMG-Nerve conduction studies
• Neurometers
• Vascular flow studies (Doppler)
• SPECT Scan
• SPECT SCAN IMAGE
• Indium 111 Scan
• Indium 111 Scan Image
• Gallium Scan
• Slide 22
• PET Scan
• PET Scan Images
• Cine MRI for TMJ
• Cine MRI images
• Root blocks-Compare to facet block
• Slide 28
• Sympathetic block-Stellate Ganglion
• Lumbar sympathetic block
• Peripheral Nerve Blocks-a test
• Neuropsychological Testing
• SCL-90
• Pain Validity Test
• Body Jacket with Thigh Spika-a test
• 2 poster brace-a test
• Blood Studies
• Epidurals of no diagnostic value